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Ichikawa, T., Haradome, H., Hachiya, J., Nitatori, T. and Araki, T. (1999), Diffusion-weighted MR imaging with single-shot echo-planar imaging in the upper abdomen: preliminary clinical experience in 61 patients. Abdominal Imaging, 24 (5), 456-461.
Abstract: Background: To determine the potential ability of diffusion- weighted magnetic resonance (MR) imaging with single-shot echo- planar imaging (DW imaging) in the upper abdomen by apparent diffusion coefficient (ADC) and signal:intensity ratio (SIR) measurements. Methods: DW imaging was performed in 61 clinical patients. ADCs in the liver, pancreas, spleen, kidney, and different pathological conditions were calculated. Spleen-to- liver SIR and segmental intensity difference of the liver (SID) were also calculated. Results: The mean ADCs (mm(2)/s) were 2.28 x 10(-3) +/- 0.07 in the liver, 1.44 x 10(-3) +/- 0.05 in the spleen, 1.94 x 10(-3) +/- 0.19 in the pancreas, and 5.76 x 10(-3) +/- 0.06 in the kidney. The mean ADC of cirrhotic liver was 1.96 x 10(-3) +/- 0.62, which was lower than that of normal liver. Other pathologic conditions also showed ADCs different from those of normal tissues. All DW images showed significantly higher spleen-to-liver SIRs and SIDs than did T2- weighted images (p < 0.05). Conclusion: The mean ADCs obtained with DW imaging were different in each upper abdominal organ and with each pathologic condition. DW images showed: better soft tissue contrast than did T2-weighted images with regard to SIR and CNR in depicting and characterizing upper abdominal disorders
Keywords: abdomen/ADC/apparent diffusion coefficient/diffusion/diffusion coefficient/diffusion study/disorders/echo/echo planar/echo planar imaging/echo-planar/echo-planar imaging/echo-planar-imaging/echoplanar/experience/imaging/kidney/LIVER/liver/lower/magnetic resonance/measurements/MR/MR imaging/NEW-YORK/PA/pancreas/patients/planar/rapid imaging/soft/STROKE/SYSTEM/T2/upper/WATER DIFFUSION
Baraff, L.J., Lee, T.J., Kader, S. and Della Penna, R. (1999), Effect of a practice guideline on the process of emergency department care of falls in elder patients. Academic Emergency Medicine, 6 (12), 1216-1223.
Abstract: Objective: To determine the effect of a practice guideline on the process of ED care in a health maintenance organization. Methods: A pre- post-intervention comparison with a one-year pre-intervention phase followed by a one-year post-educational intervention phase was used to study the effect of the guideline on ED care. Emergency physicians and nurses were provided the details of the guideline during a two-week interval between the two periods. Results: During the two years of the study, 1,140 preintervention and 759 post-intervention patients met study eligibility criteria. More patients were diagnosed as having had falls due to loss of consciousness, stroke, and seizures during the post-intervention period (pre- intervention 3.8% vs post-intervention 8.4%, p < 0.001). There was a significant improvement in documentation of six of ten history items: cause of fall (64.5% vs 72.9%), location of fall (54.7% vs 60.5%), ability to get up unassisted (5.4% vs 12.5%), long lie after fall (1.5% vs 10.1%), prescription medications (79.0% vs 92.2%), and Pneumovax immunization status (20.8% vs 43.0%); and two of the four physical examination items: visual acuity (1.5% vs 3.2%) and the "get up and go test" (1.3% vs 11.2%). Prescribing of calcium and vitamin D increased from 0% to 6.6%. Conclusions: The educational intervention to the practice guideline for the ED management of falls in elders led to small but significant improvements in the documentation of selected history and physical examination items and the prescribing of calcium and vitamin D, and to a greater consideration of the causes of falls
Keywords: accidental falls-prevention and control/aged/CA/calcium/causes/CLINICAL GUIDELINES/COMMUNITY/consciousness/criteria/effect/emergency/emergency department/emergency medicine/falls/geriatric assessment/guideline/health/health maintenance/history/HOME/improvement/intervention/loss/loss of consciousness/MANAGEMENT/MEDICINE/nurses/PA/patients/PEOPLE/PHILADELPHIA/POLICY/POPULATION/practice/practice guidelines/process/RANDOMIZED TRIAL/RISK-FACTORS/seizures/small/status/stroke/visual/vitamin D
Kunnel, B. and Heller, M. (1999), Thrombolytics and stroke: What do emergency medicine residents perceive? Academic Emergency Medicine, 6 (11), 1174-1176
Keywords: emergency/emergency medicine/emergency medicine residents/medicine/PA/PHILADELPHIA/stroke/thrombolytics
Morris, D.L., Rosamond, W.D., Hinn, A.R. and Gorton, R.A. (1999), Time delays in accessing stroke care in the emergency department. Academic Emergency Medicine, 6 (3), 218-223.
Abstract: Objective: To delineate components of delay within the hospital ED for patients presenting with symptoms of stroke. Methods: A prospective registry of patients presenting to the ED with signs or symptoms of stroke was established at a university hospital from July 1995 to March 1996. The ED ar rival time, time to being seen by an emergency physician (EP), time to CT scan, and time to neurology consultation were obtained by medical record review. Results: The median delay (interquartile range) from ED arrival to being seen by an EP for the 170 eligible subjects was 0.42 (0.20-0.75) hours. The median delay to CT scan was 1.88 hours (1.25-2.67) and the median delay to neurology consultation was 2.42 hours (1.50-3.48). Age, race, sex, and hospital discharge diagnosis had little influence on delay. Subjects arriving by emergency medical services (EMS) had a significantly shorter time to being seen by an EP (0.33 vs 0.50 hours) when compared with those who arrived by other means. Time to CT scan was shorter by 0.5 hours for patients arriving by EMS as well. These differences persisted when stratified by out-of-hospital delay times. Conclusions: These data suggest that arriving by EMS is associated with shorter times to being seen by an EP and receiving a CT scan. The influence of EMS on delays associated with rapid medical care of stroke patients reaches beyond the out-of-hospital transport phase
Keywords: ACUTE MYOCARDIAL-INFARCTION/cerebral infarction/CT/CT scan/CT scans/delay/delay in care/diagnosis/emergency/emergency department/emergency medical services/EMS/hospital/hospital discharge/medical/neurology/out-of-hospital/PA/patients/PHILADELPHIA/prospective/race/rapid care/registry/review/sex/stratified/stroke/stroke patients/symptoms/transport
Smith, R.W., Scott, P.A., Grant, R.J., Chudnofsky, C.R. and Frederiksen, S.M. (1999), Emergency physician treatment of acute stroke with recombinant tissue plasminogen activator: A retrospective analysis. Academic Emergency Medicine, 6 (6), 618-625.
Abstract: Stroke teams are advocated for the rapid treatment of patients who have acute ischemic stroke (AIS) with recombinant tissue plasminogen activator (rt-PA). An alternate model uses existing ED resources with specialist consultation as needed.. Objectives: To evaluate the treatment of AIS with rt-PA in this alternate ED model. Methods: A retrospective observational review was performed of consecutive patients with AIS treated with rt-PA at four hospitals affiliated with an emergency medicine residency. Emergency physicians (EPs) were. directly responsible for the treatment of all patients according to predefined guidelines. Records were evaluated from the implementation of the guidelines through December 15, 1997. Results: 37 patients with AIS received rt-PA. Mean age +/- SD was 63 +/- 16 years (range 22-87), with 25 (68%) male. Patients presented 67 +/- 29 minutes after stroke onset. After ED- arrival, they were seen by the EP in 14 +/- 13 minutes, had CT in 46 +/- 22 minutes, and were treated in 97 +/- 35 minutes. Neurologist consultation occurred in the department for nine patients (24.3%), and by telephone for 14 (37.8%). Symptomatic intracerebral hemorrhage (ICH) occurred in four (10.8%, 95% CI = 0.8% to 20.8%). There were two deaths, neither associated with ICH. Neurologic outcome at discharge compared with presentation in survivors was normal for four patients (11.4%), improved for 16 (45.7%), unchanged for ten (28.6%), and worse for five (14.3%). Conclusions: In this analysis, EPs, with specialty consultation as required, successfully identified patients with AIS and delivered rt-PA with satisfactory outcomes. Important elements of this model include early patient identification, preestablished protocols, and rapid access to CT scanning and interpretation
Keywords: ACCURACY/acute/acute ischemic/ACUTE ISCHEMIC STROKE/acute stroke/age/analysis/cerebral infarction/cerebral ischemia/CT/deaths/DELAYS/emergency/emergency medicine/guidelines/hemorrhage/hospitals/implementation/interpretation/intracerebral/intracerebral hemorrhage/ischemic/ischemic stroke/JUN/male/MANAGEMENT/medicine/model/observational/onset/outcome/outcomes/PA/patients/PHILADELPHIA/plasminogen/plasminogen activator/presentation/protocols/recombinant/recombinant tissue plasminogen activator/review/rt-PA/rtPA/stroke/stroke onset/THROMBOLYTIC THERAPY/thrombolytic therapy/tissue plasminogen/tissue plasminogen activator/treatment/TRIAL
Casebeer, L.L., Klapow, J.C., Centor, R.M., Stafford, M.A., Renkl, L.A., Mallinger, A.P. and Kristofco, R.E. (1999), An intervention to increase physicians' use of adherence- enhancing strategies in managing hypercholesterolemic patients. Academic Medicine, 74 (12), 1334-1339.
Abstract: Purpose. Patients' lack of adherence to medical regimens frustrates many practicing physicians. This study was conducted to determine the effectiveness of a combined continuing medical education intervention in increasing physicians' adherence- enhancing skills and improving hypercholesterolemic patients' health. Method. A prospective, randomized, controlled trial was designed using a nested cohort of 28 community physicians throughout Alabama and 222 of their hypercholesterolemic outpatients, The intervention, carried out in 1998, consisted of three interactive case audio-conferences plus chart reminders. Physicians' learning was measured by unannounced standardized patients, and patients' health by serum cholesterol levels, weight, knowledge of hypercholesterolemia, self-reported dietary habits, and health status. Results. No significant difference was found in the numbers of physician adherence-enhancing strategies, although the number did increase within the treatment group. There were significant differences in the intervention group's patients' knowledge of cholesterol management (p =.008) and significant reductions in their self-reported consumption of dietary fats (p =.002). A significant difference was found in the serum cholesterol level of men in the intervention group nine months after the intervention (p =.02), Conclusion. Combining a series of interactive case audio-conferences with charr reminders shows promise in increasing physicians' adherence-enhancing strategies. In chronic disease management, the problem of enhancing adherence remains complex
Keywords: adherence/AL/cholesterol/cholesterol levels/chronic/chronic disease/cohort/combined/community/consumption/dietary/disease/disease management/education/effectiveness/fats/health/health status/hypercholesterolemia/intervention/knowledge/learning/management/medical/medical education/men/PA/patients/PHILADELPHIA/PREVENTION/prospective/randomized/serum/serum cholesterol/standardized patients/status/strategies/STROKE MORTALITY/treatment/trial/UNITED-STATES/use/weight
Eyraud, D., Benmalek, F., Teugels, K., Bertrand, M., Mouren, S. and Coriat, P. (1999), Does desflurane alter left ventricular function when used to control surgical stimulation during aortic surgery? Acta Anaesthesiologica Scandinavica, 43 (7), 737-743.
Abstract: Background: Although desflurane is commonly used to control surgically induced hypertension, its effects on left ventricular (LV) function have not been investigated in this clinical situation. The purpose of the present study was to evaluate the LV function response to desflurane, when used to control intraoperative hypertension. Methods: In 50 patients, scheduled for vascular surgery, anesthesia was induced with sufentanil 0.5 mu g/kg, midazolam 0.3 mg/kg and atracurium 0.5 mg/kg. After tracheal intubation, anesthesia was maintained with increments of drugs with controlled ventilation (N2O/O- 2=60/40%) until the start of surgery. A 5 Mhz transesophageal echocardiography (TEE) probe was inserted after intubation. Pulmonary artery catheter and TEE measurements were obtained after induction (to)(control value), at surgical incision (t(1)) if it was associated with an increase in systolic arterial pressure (SAP) greater than 140 mmHg (hypertension) and after control of hemodynamic parameters by administration of desflurane (return of systolic arterial pressure to within 20% of the control value) (t(2)) in a fresh gas flow of 3 1/ min. Results: Sixteen patients developed hypertension at surgical incision. SAP was controlled by desflurane in all 16 patients. Afterload assessed by systemic vascular resistance index (SVRI), end-systolic wall-stress (ESWS) and left- ventricular stroke work index (LVSWI) increased with incision until the hypertension returned to post-induction values with mean end-tidal concentration of 5.1+/-0.7% desflurane. No change in heart rate, cardiac index, mean pulmonary arterial pressure, stroke volume, end-diastolic and end-systolic cross- sectional areas, fractional area change and left ventricular circumferential fiber shortening was noted when desflurane was added to restore blood pressure. Conclusion: This study demonstrates that in patients at risk for cardiac morbidity undergoing vascular surgery, desflurane is effective to control intraoperative hypertension without fear of major cardiac depressant effect
Keywords: administration/anesthesia/ANESTHESIA/aortic/aortic surgery/arterial/arterial pressure/artery/blood/blood pressure/BOX/cardiac/cardiac index/CARDIAC-FUNCTION/catheter/circumferential fiber shortening/control/COPENHAGEN/DENMARK/desflurane/drugs/ECHOCARDIOGRAPHY/effect/effects/FENTANYL/fiber/flow/fractional area change/function/gas/heart/heart rate/hemodynamic/hemodynamic parameters/HUMANS/hypertension/index/intraoperative/intraoperative hypertension/intubation/ISOFLURANE/left/left ventricular/left ventricular function/left ventricular stroke work/left ventricular stroke work index/LVSWI/measurements/midazolam/morbidity/patients/pressure/pulmonary/rate/resistance/response/RESPONSES/risk/stimulation/stroke/stroke volume/stroke work/sufentanil/surgery/systemic/systemic vascular resistance/systemic vascular resistance index/systolic/TEE/transesophageal/transesophageal echocardiography/TRANSIENT CARDIOVASCULAR STIMULATION/VALIDATION/vascular/vascular resistance/vascular surgery/ventilation/ventricular function/volume/VOLUNTEERS/work
Gullberg, N., Winberg, P. and Sellden, H. (1999), Changes in stroke volume cause change in cardiac output in neonates and infants when mean airway pressure is altered. Acta Anaesthesiologica Scandinavica, 43 (10), 999-1004.
Abstract: Background: Based on early studies in the lamb, and in spite of more recent studies in humans, it has been the received opinion that neonates and infants can not change their stroke volume significantly, but are mainly dependent on changes in heart rate, to change cardiac output. To further evaluate the relationship between cardiac output and stroke volume during mechanical ventilation of neonates and infants, we have studied the effects on cardiac output and stroke volume by two different ways of changing mean airway pressure. Methods: In one group, mean airway pressure was decreased by using a patient triggered mode: pressure support ventilation; in the other, mean airway pressure was increased by increasing positive end-expiratory pressure (PEEP). Changes in cardiac output, heart rate and stroke volume were assessed with the Doppler technique, measuring blood flow velocity in the ascending aorta. Results: Without a significant change in heart rate, we found a significant increase in cardiac output of +16 +/- 2% (P<0.01) with a decrease in mean airway pressure and a decrease in cardiac output of -13 +/- 4%, (P<0.02) with an increase in mean airway pressure, depicting a change in stroke volume of +17 +/- 2% (P<0.02) and -14 +/- 5%, (P<0.01) respectively. Conclusions: We conclude that neonates and infants are able to regulate cardiac output by changing the stroke volume to a greater extent than presumed, at least when cardiac output is influenced by changes in the mean airway pressure
Keywords: aorta/ascending/ascending aorta/ATROPINE/blood/blood flow/blood flow velocity/BLOOD-FLOW/BOX/cardiac/cardiac output/CHILDREN/COPENHAGEN/DENMARK/Doppler/DOPPLER ECHOCARDIOGRAPHY/effects/flow/flow velocity/heart/heart rate/HEART-RATE/humans/infants/mean airway pressure/mechanical/mechanical ventilation/neonatal/neonates/pediatric/PEEP/positive end-expiratory pressure/pressure/rate/stroke/stroke volume/studies/support/Sweden/technique/velocity/ventilation/volume
van der Meer, B.J.M., Noordegraaf, A.V., Bax, J.J., Kamp, O. and de Vries, P.M.J.M. (1999), Non-invasive evaluation of left ventricular function by means of impedance cardiography. Acta Anaesthesiologica Scandinavica,
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